Provisional publication of Never Events reported as ... · 3 Provisional publication of Ne | ver Events reported as occurring 1 April - 31 December 2019 These standards set out broad

NHS England and NHS Improvement

Provisional publication of Never Events reported as occurring between 1 April and 31 December 2019

Published 30 January 2020

1 | Provisional publication of Never Events reported as occurring 1 April - 31 December 2019

Contents

Never Events ............................................................................................................ 2

Supporting healthcare providers to prevent Never Events .................................... 2

Investigating and learning from Never Events ....................................................... 4

Important notes on the provisional nature of this data ........................................... 4

Summary .................................................................................................................. 5

2 | Provisional publication of Never Events reported as occurring 1 April - 30 November 2019

Never Events

Never Events are serious, largely preventable patient safety incidents that should not

occur if healthcare providers have implemented existing national guidance or safety

recommendations. The Never Events policy and framework – revised January 2018

explains that Never Events may highlight potential weaknesses in how an organisation

manages fundamental safety processes. Never Events are different from other serious

incidents as the overriding principle of having the Never Events list is that even a single

Never Event acts as a red flag that an organisation’s systems for implementing existing

safety advice/alerts may not be robust.

The concept of Never Events is not about apportioning blame to organisations when these

incidents occur but rather to learn from what happened. This is why, following consultation,

in the revised Never Events policy and framework – published January 2018 we removed

the option for commissioners to impose financial sanctions when Never Events were

reported. The foreword to the framework states: “……allowing commissioners to impose

financial sanctions following Never Events reinforced the perception of a ‘blame culture’.

Our removal of financial sanctions should not be interpreted as a weakening of effort to

prevent Never Events. It is about emphasising the importance of learning from their

occurrence, not blaming.” Identifying and addressing the reasons behind this can

potentially improve safety in ways that extend far beyond the department where the Never

Event occurred, or the type of procedure involved.

Please note that because the definitions and designated list of Never Events were revised

from February 2018, direct comparison of the number of Never Events with earlier periods

is not appropriate.

The revised 2018 Never Events Policy and Framework requires commissioners and

providers to agree and report Never Events via the Strategic Executive Information System

(StEIS). Where a Serious Incident is logged as a Never Event but does not appear to fit

any definition on the Never Events list 2018 (published 31 January 2018) commissioners

are asked to discuss this with the provider organisation and either add extra detail to StEIS

to confirm it is a Never Event or remove its Never Event designation from the StEIS

system.

Supporting healthcare providers to prevent Never Events

To help prevent Never Events a set of new National Safety Standards for Invasive

Procedures (NatSSIPs) was published in September 2015, and all relevant NHS

organisations in England have now been instructed to develop and implement their own

local standards based on the national principles of the NatSSIPs.

https://improvement.nhs.uk/resources/never-events-policy-and-framework/



https://improvement.nhs.uk/resources/national-safety-standards-invasive-procedures/

https://improvement.nhs.uk/resources/national-safety-standards-invasive-procedures/


These standards set out broad principles of safe practice and advise healthcare

professionals on how they can implement best practice: for example, through a series of

standardised safety checks and education and training. The standards also support NHS

providers to work with staff to develop and maintain their own, more detailed, local

standards and encourage organisations to share best practice.

To help prevent nasogastric Never Events an Alert Nasogastric tube misplacement:

continuing risk of death and severe harm and resource set were published by NHS

Improvement in July 2016. These provide materials to help trust boards, or their

equivalents, assess whether previous alerts and guidance about nasogastric tubes have

been implemented and embedded in their organisations.

To help prevent the use of curtain or shower rails being used as a ligature point, an

Estates and Facilities Alert Anti-ligature’ type curtain rail systems: Risks from incorrect

installation or modification has been published in March 2019. The alert is not accessible

publicly but can be accessed via log in to the Central Alerting System.

The Care Quality Commission has undertaken a recent thematic review in collaboration

with NHS Improvement to get a better understanding of what can be done to prevent the

occurrence of Never Events. The report ‘Opening the door to change’ was published in

December 2018.

The report found that: “Never Events continue to happen despite the hard work and efforts

of frontline staff. Staff are struggling to cope with large volumes of safety guidance, they

have little time and space to implement guidance effectively, and the systems and

processes around them are not always supportive. Where staff are trying to implement

guidance, they are often doing this on top of a demanding and busy role that makes it

difficult to give the work the time it requires.”

The report includes a recommendation that “NHS Improvement should review the Never

Events framework and work with professional regulators and royal colleges to take

account of the difference in the strength of different kinds of barrier to errors (such as

distinguishing between those that should be prevented by human interactions and

behaviours such as using checklists, counts and sign-in processes; and those that could

be designed out entirely such as through the removal of equipment or fitting/using physical

barriers to risks). This review should focus on the leadership and culture needed to

underpin safety. It should take into account the different settings in which Never Events

occur, including acute, mental health and community settings” This work may involve

changes to the approach of the Never Events framework and the list of Never Events in

the future.

https://improvement.nhs.uk/news-alerts/nasogastric-tube-misplacement-continuing-risk-of-death-severe-harm/

https://improvement.nhs.uk/resources/resource-set-initial-placement-checks-nasogastric-and-orogastric-tubes/

https://www.cas.mhra.gov.uk/Home.aspx

https://www.cqc.org.uk/publications/themed-work/opening-door-change


Investigating and learning from Never Events

NHS providers are encouraged to learn from mistakes and any organisation that reports a

Never Event is expected to conduct its own investigation so it can learn and take action on

the underlying causes.

The fact that more and more NHS staff take the time to report incidents is good evidence

that this learning is happening locally. We continue to encourage NHS staff to report Never

Events and Serious Incidents to StEIS and all patient safety incidents to the National

Reporting and Learning System (NRLS), to help us identify any risks so that necessary

action can be taken.

Important notes on the provisional nature of this data

To support learning from Never Events we are committed to publishing this data as early

as possible. However, because reports of apparent Never Events are submitted by

healthcare providers as soon as possible, often before local investigation is complete, all

data is provisional and subject to change.

Because of the complex combination of incidents identified as Never Events when first

reported, Serious Incidents designated as Never Events at a later date, and incidents

initially reported as Never Events that on investigation are found not to meet the criteria,

our monthly provisional Never Event reports provide cumulative totals for the current

financial year. This is to ensure the information provided is as consistent and as accurate

as possible.

This provisional report is drawn from the StEIS system and includes all Serious Incidents

with a reported incident date between 1 April and 31 December 2019, and which on 9

January 2020 were designated by their reporters as Never Events.

Data on Never Events for 2018/19 and previous years can be found on the NHS

Improvement website.

Once sufficient time has elapsed after the end of the 2019/20 reporting year for local

incident investigation and national analysis of data, we will produce a final whole-year

report of Never Events, which will replace this provisional data.

https://improvement.nhs.uk/resources/never-events-data/


Summary

When data for this report was extracted on 9 January 2020, 381 Serious Incidents on the

StEIS system were designated by their reporters as Never Events and had a reported

incident date between 1 April and 31 December 2019. Of these 381 incidents:

• 350 Serious Incidents appeared to meet the definition of a Never Event in the Never

Events list 2018 (published 31 January 2018) and had an incident date between 1

April and 31 December 2019; this number is subject to change as local

investigations are completed

• 31 Serious Incidents did not appear to meet the definition of a Never Event and had

an incident date between 1 April and 31 December 2019.

More detail is provided in the tables below:

Table 1: Never Events 1 April to 31 December 2019 by month of incident*

Month in which Never Event occurred Number

April 35

May 48

June 42

July 41

August 47

September 39

October 30

November 35

December 33

Total 350

Note: As described above, a further 31 Serious Incidents did not appear to meet the

definition of a Never Event and the relevant organisations have been asked to review them

accordingly.

*Numbers are subject to change as local investigations are completed.




Table 2: Never Events 1 April to 31 December 2019 by type of incident with additional detail*

Type and brief description of Never Event Number

Wrong site surgery 176

Central line intended for another patient 1

Circumcision instead of planned frenuloplasty 1

Colposcopy intended for another patient 1

Contrast injection to wrong breast 1

Cystoscopy instead of sigmoidoscopy 1

Fallopian tube removed in error when plan was to remove the appendix 1

Flexible cystoscopy intended for another patient 1

Gastroscopy instead of colonoscopy 1

Gastroscopy intended for another patient 1

Gastrostomy instead of colostomy 1

Incision to wrong eye lid 1

Incision to wrong finger 1

Incision to wrong side of gum 1

Incision to wrong side of knee 1

Injection to face rather than neck 1

Injection to wrong breast 1

Injection to wrong eye 6

Injection to wrong eye muscle 1

Injection to wrong finger joint 1

Injection to wrong foot 1

Injection to wrong joint 1

Injection to wrong leg 2

Injections to both eyelids instead of one 1

Injections to both eyes rather than one 1

Knee injection instead of elbow aspiration 1

Lesion removed from neck instead of gum 1

Lumbar puncture intended for another patient 2

Needle aspiration of wrong lung 2

Part of pancreas removed instead of adrenal gland 1

Perineal fistulotomy instead of incision and drainage of pilonidal abscess 1

Pilonidal sinus excised instead of groin abscess 1

Ureteroscopy intended for another patient 1

Varicose vein removal from the wrong leg 1

Wrong area of breast tissue removed 2

Wrong breast lesion removed 2

Wrong eye procedure 1

Wrong finger 2


Wrong finger incision 2

Wrong finger injection 1

Wrong hernia incision 1

Wrong hernia repair 1

Wrong rectus muscle in squint surgery 1

Wrong side angiogram 1

Wrong side ankle arthroscopy 1

Wrong side chest drain 3

Wrong side hernia repair 1

Wrong side labial lesion removed 1

Wrong side of leg 1

Wrong side of nose 1

Wrong side of toe nail removed 1

Wrong side parietal catheter 1

Wrong side spinal injection 9

Wrong side spinal surgery 2

Wrong side ureteric stent 2

Wrong site block 45

Wrong site pleural aspiration 1

Wrong skin lesion biopsy 2

Wrong skin lesion removed 11

Wrong testicle 1

Wrong toe 1

Wrong vulval lesion removed 2

Wrong tooth/teeth removed 33

Cervical biopsy instead of colon/rectal biopsy 1

K wires to wrong part of thumb 1

Retained foreign object post procedure 71

Angioplasty cover 1

Bladder resectoscope tip 1

Corneal guard 1

Coronary wire 1

Guide wire - Anterior Cruciate Ligament reconstruction 1

Guide wire - central line 13

Guide wire - chest drain 5

Guide wire - gastrostomy stent 1

Guide wire - PICC line 2

Guide wire - renal dialysis line 1

Guide wire - ureteric stent 1

Laser eye shield 1

Ophthalmic pars plana vitrectomy (PPV) port 1

Ophthalmic trocar 1


Part of a dental instrument 1

Part of a Jacques catheter 1

Part of a periosteal elevator 1

Part of a uterine manipulator 1

Part of a vascular ablation sheath 1

PEG insertion device 1

Renal catheter inserter 1

Rubber collar from uterine manipulator 1

Surgical forcep 1

Surgical needle 3

Surgical swab 13

Throat pack 1

Tip of resectoscope 2

Vaginal swab 11

Bladder loop 1

Wrong implant/prosthesis 37

Femoral nail 1

Fracture fixation plate - right instead of left 1

Hip 8

Intramedullary nail 1

Intra uterine device 4

IUCD implanted that was not consented for 1

Knee 12

Lens 7

Shoulder 1

Wrong breast implant 1

Unintentional connection of a patient requiring oxygen to an air flowmeter 22

Patient connected to air flowmeter rather than oxygen 22

Misplaced naso or oro gastric tube 18

Naso gastric tube in the respiratory tract and feed administered 18

Administration of medication by the wrong route 7

Enteral medication given intravenously 1

Oral medication given intravenously 4

Oral medication given subcutaneously 2

Overdose of methotrexate for non-cancer treatment 6

Methotrexate overdose prescribed and administered 6

Overdose of insulin due to abbreviations or incorrect device 5

Insulin withdrawn from an insulin pen 1

Wrong syringe 4

Transfusion or transplantation of ABO incompatible blood components or organs 3

Wrong blood transfused 3


Mis selection of high strength midazolam during conscious sedation 3

Wrong strength midazolam administered 3

Mis selection of a strong potassium solution 1

Wrong strength potassium given 1

Failure to install functional collapsible shower or curtain rails 1

Curtain rail failed to collapse 1

Total 350

Note: As described above, a further 31 Serious Incidents did not appear to meet the

definition of a Never Event and the relevant organisations have been asked to review them

accordingly.

*Numbers are subject to change as local investigations are completed.


Table 3: Never Events 1 April to 31 December 2019 by healthcare provider*

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Birmingham Women's and Children's NHS Foundation Trust

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BMI - The Lancaster Hospital, reported by NHS East Lancashire CCG

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Buckinghamshire Healthcare NHS Trust

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Calderdale and Huddersfield NHS Foundation Trust

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Cambridge University Hospitals NHS Foundation Trust

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East Kent Hospitals University NHS Foundation Trust

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East Lancashire Hospitals NHS Trust 2 1 3

East Suffolk and North Essex NHS Foundation Trust

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East Sussex Healthcare NHS Trust 1 3 4

Emersons Green NHS Treatment Centre, reported by NHS Bristol North Somerset and South Gloucestershire CCG

1 1

Epsom and St Helier University Hospitals NHS Trust

1 2 3

Frimley Health NHS Foundation Trust 1 1 1 3


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nti

on

al c

on

ne

cti

on

of

a p

ati

en

t re

qu

irin

g o

xyg

en

to

an

air

flo

wm

ete

r

Wro

ng

im

pla

nt/

pro

sth

esis

Wro

ng

sit

e s

urg

ery

To

tal

Gateshead Health NHS Foundation Trust

1 1

George Eliot Hospital NHS Trust 1 1

Gloucestershire Health and Care NHS Foundation Trust

2 2

Gloucestershire Hospitals NHS Foundation Trust

1 1 2

Great Ormond Street Hospital for Children NHS Foundation Trust

1 1

Great Western Hospitals NHS Foundation Trust

1 1 2

Guy's and St Thomas' NHS Foundation Trust

1

1 1 1 3 7

Hampshire Hospitals NHS Foundation Trust

1 1 2 4


Ad

min

istr

ati

on

of

me

dic

ati

on

by t

he w

ron

g r

ou

te

Fail

ure

to

in

sta

ll f

un

cti

on

al

co

lla

psib

le s

ho

wer

or

cu

rta

in

rail

s

Mis

sele

cti

on

of

a s

tro

ng

po

tass

ium

so

luti

on

Mis

sele

cti

on

of

hig

h

str

en

gth

mid

azo

lam

du

rin

g

co

nsc

iou

s s

ed

ati

on

Mis

pla

ce

d n

as

o o

r o

ro

gas

tric

tu

be

Ov

erd

os

e o

f in

su

lin

du

e t

o

ab

bre

via

tio

ns

or

inco

rre

ct

dev

ice

Ov

erd

ose o

f m

eth

otr

exa

te

for

no

n-c

an

ce

r tr

ea

tmen

t

Re

tain

ed

fo

reig

n o

bje

ct

po

st

pro

ce

du

re

Tra

ns

fus

ion

or

tra

nsp

lan

tati

on

of

AB

O

inco

mp

ati

ble

blo

od

co

mp

on

en

ts o

r o

rga

ns

Un

inte

nti

on

al c

on

ne

cti

on

of

a p

ati

en

t re

qu

irin

g o

xyg

en

to

an

air

flo

wm

ete

r

Wro

ng

im

pla

nt/

pro

sth

esis

Wro

ng

sit

e s

urg

ery

To

tal

Homerton University Hospital NHS Foundation Trust

1 1 1 3

Hull University Teaching Hospitals NHS Trust

1 1 1 4 7

Imperial College Healthcare NHS Trust 1 1 2

InHealth, Mobile Endoscopy Unit, reported by NHS Manchester CCG

1 1

Ironstone Centre, Scunthorpe, reported by NHS North Lincolnshire CCG

1 1

iSIGHT Private Eye Care, Southport, reported by NHS South Sefton CCG

1 1

Isle of Wight NHS Trust 1 1

James Paget University Hospitals NHS Foundation Trust

1 1


Ad

min

istr

ati

on

of

me

dic

ati

on

by t

he w

ron

g r

ou

te

Fail

ure

to

in

sta

ll f

un

cti

on

al

co

lla

psib

le s

ho

wer

or

cu

rta

in

rail

s

Mis

sele

cti

on

of

a s

tro

ng

po

tass

ium

so

luti

on

Mis

sele

cti

on

of

hig

h

str

en

gth

mid

azo

lam

du

rin

g

co

nsc

iou

s s

ed

ati

on

Mis

pla

ce

d n

as

o o

r o

ro

gas

tric

tu

be

Ov

erd

os

e o

f in

su

lin

du

e t

o

ab

bre

via

tio

ns

or

inco

rre

ct

dev

ice

Ov

erd

ose o

f m

eth

otr

exa

te

for

no

n-c

an

ce

r tr

ea

tmen

t

Re

tain

ed

fo

reig

n o

bje

ct

po

st

pro

ce

du

re

Tra

ns

fus

ion

or

tra

nsp

lan

tati

on

of

AB

O

inco

mp

ati

ble

blo

od

co

mp

on

en

ts o

r o

rga

ns

Un

inte

nti

on

al c

on

ne

cti

on

of

a p

ati

en

t re

qu

irin

g o

xyg

en

to

an

air

flo

wm

ete

r

Wro

ng

im

pla

nt/

pro

sth

esis

Wro

ng

sit

e s

urg

ery

To

tal

Kettering General Hospital NHS Foundation Trust

1 1

King's College Hospital NHS Foundation Trust

1 2 3

Kingston Hospital NHS Foundation Trust

1 1

Lancashire Teaching Hospitals NHS Trust

1 1

Leeds Teaching Hospitals NHS Trust 1 1 1 3

Lewisham and Greenwich NHS Trust 1 2 3

Liverpool Heart and Chest Hospital NHS Foundation Trust

1 1

Liverpool University Hospitals NHS Foundation Trust

1 1


Ad

min

istr

ati

on

of

me

dic

ati

on

by t

he w

ron

g r

ou

te

Fail

ure

to

in

sta

ll f

un

cti

on

al

co

lla

psib

le s

ho

wer

or

cu

rta

in

rail

s

Mis

sele

cti

on

of

a s

tro

ng

po

tass

ium

so

luti

on

Mis

sele

cti

on

of

hig

h

str

en

gth

mid

azo

lam

du

rin

g

co

nsc

iou

s s

ed

ati

on

Mis

pla

ce

d n

as

o o

r o

ro

gas

tric

tu

be

Ov

erd

os

e o

f in

su

lin

du

e t

o

ab

bre

via

tio

ns

or

inco

rre

ct

dev

ice

Ov

erd

ose o

f m

eth

otr

exa

te

for

no

n-c

an

ce

r tr

ea

tmen

t

Re

tain

ed

fo

reig

n o

bje

ct

po

st

pro

ce

du

re

Tra

ns

fus

ion

or

tra

nsp

lan

tati

on

of

AB

O

inco

mp

ati

ble

blo

od

co

mp

on

en

ts o

r o

rga

ns

Un

inte

nti

on

al c

on

ne

cti

on

of

a p

ati

en

t re

qu

irin

g o

xyg

en

to

an

air

flo

wm

ete

r

Wro

ng

im

pla

nt/

pro

sth

esis

Wro

ng

sit

e s

urg

ery

To

tal

Liverpool Women's NHS Foundation Trust

1 1

London North West University Healthcare NHS Trust

1 1 2

Luton and Dunstable University Hospital NHS Foundation Trust

1 1 2

Manchester University NHS Foundation Trust

1 1 2 2 6

Medway NHS Foundation Trust 2 2

Mid Cheshire Hospitals NHS Foundation Trust

1 1

Mid Essex Hospital Services NHS Trust

1 1

Mid Yorkshire Hospitals NHS Trust 1 1 1 3


Ad

min

istr

ati

on

of

me

dic

ati

on

by t

he w

ron

g r

ou

te

Fail

ure

to

in

sta

ll f

un

cti

on

al

co

lla

psib

le s

ho

wer

or

cu

rta

in

rail

s

Mis

sele

cti

on

of

a s

tro

ng

po

tass

ium

so

luti

on

Mis

sele

cti

on

of

hig

h

str

en

gth

mid

azo

lam

du

rin

g

co

nsc

iou

s s

ed

ati

on

Mis

pla

ce

d n

as

o o

r o

ro

gas

tric

tu

be

Ov

erd

os

e o

f in

su

lin

du

e t

o

ab

bre

via

tio

ns

or

inco

rre

ct

dev

ice

Ov

erd

ose o

f m

eth

otr

exa

te

for

no

n-c

an

ce

r tr

ea

tmen

t

Re

tain

ed

fo

reig

n o

bje

ct

po

st

pro

ce

du

re

Tra

ns

fus

ion

or

tra

nsp

lan

tati

on

of

AB

O

inco

mp

ati

ble

blo

od

co

mp

on

en

ts o

r o

rga

ns

Un

inte

nti

on

al c

on

ne

cti

on

of

a p

ati

en

t re

qu

irin

g o

xyg

en

to

an

air

flo

wm

ete

r

Wro

ng

im

pla

nt/

pro

sth

esis

Wro

ng

sit

e s

urg

ery

To

tal

Moorfields Eye Hospital NHS Foundation Trust

1 1 2

Mount Stuart Hospital, Ramsay Health Care UK, reported by NHS Devon CCG

1 1

My Dentist, Bridgwater, reported by Somerset CCG

3 3

My Dentist, Hebburn, reported by NHS England - Cumbria and North East

1 1

My Dentist, Newton Abbot, reported by NHS Devon CCG

1 1

Navigo, reported by another provider 1 1

Newcastle upon Tyne Hospitals NHS Foundation Trust

1

3 4


Ad

min

istr

ati

on

of

me

dic

ati

on

by t

he w

ron

g r

ou

te

Fail

ure

to

in

sta

ll f

un

cti

on

al

co

lla

psib

le s

ho

wer

or

cu

rta

in

rail

s

Mis

sele

cti

on

of

a s

tro

ng

po

tass

ium

so

luti

on

Mis

sele

cti

on

of

hig

h

str

en

gth

mid

azo

lam

du

rin

g

co

nsc

iou

s s

ed

ati

on

Mis

pla

ce

d n

as

o o

r o

ro

gas

tric

tu

be

Ov

erd

os

e o

f in

su

lin

du

e t

o

ab

bre

via

tio

ns

or

inco

rre

ct

dev

ice

Ov

erd

ose o

f m

eth

otr

exa

te

for

no

n-c

an

ce

r tr

ea

tmen

t

Re

tain

ed

fo

reig

n o

bje

ct

po

st

pro

ce

du

re

Tra

ns

fus

ion

or

tra

nsp

lan

tati

on

of

AB

O

inco

mp

ati

ble

blo

od

co

mp

on

en

ts o

r o

rga

ns

Un

inte

nti

on

al c

on

ne

cti

on

of

a p

ati

en

t re

qu

irin

g o

xyg

en

to

an

air

flo

wm

ete

r

Wro

ng

im

pla

nt/

pro

sth

esis

Wro

ng

sit

e s

urg

ery

To

tal

Norfolk and Norwich University Hospitals NHS Foundation Trust

3 2 5

Norfolk Community Health and Care NHS Trust

1 1

North Bristol NHS Trust 1 1

North Cumbria Integrated Care NHS Foundation Trust

1 1

North Middlesex University Hospital NHS Trust

1 1

North Tees and Hartlepool NHS Foundation Trust

1 1

North West Anglia NHS Foundation Trust

1 1

Northampton General Hospital NHS Trust

1 1 2


Ad

min

istr

ati

on

of

me

dic

ati

on

by t

he w

ron

g r

ou

te

Fail

ure

to

in

sta

ll f

un

cti

on

al

co

lla

psib

le s

ho

wer

or

cu

rta

in

rail

s

Mis

sele

cti

on

of

a s

tro

ng

po

tass

ium

so

luti

on

Mis

sele

cti

on

of

hig

h

str

en

gth

mid

azo

lam

du

rin

g

co

nsc

iou

s s

ed

ati

on

Mis

pla

ce

d n

as

o o

r o

ro

gas

tric

tu

be

Ov

erd

os

e o

f in

su

lin

du

e t

o

ab

bre

via

tio

ns

or

inco

rre

ct

dev

ice

Ov

erd

ose o

f m

eth

otr

exa

te

for

no

n-c

an

ce

r tr

ea

tmen

t

Re

tain

ed

fo

reig

n o

bje

ct

po

st

pro

ce

du

re

Tra

ns

fus

ion

or

tra

nsp

lan

tati

on

of

AB

O

inco

mp

ati

ble

blo

od

co

mp

on

en

ts o

r o

rga

ns

Un

inte

nti

on

al c

on

ne

cti

on

of

a p

ati

en

t re

qu

irin

g o

xyg

en

to

an

air

flo

wm

ete

r

Wro

ng

im

pla

nt/

pro

sth

esis

Wro

ng

sit

e s

urg

ery

To

tal

Northern Devon Healthcare NHS Trust 1 1

Northern Lincolnshire and Goole NHS Foundation Trust

1 1

Northumberland, Tyne and Wear NHS Foundation Trust

1

1

Northumbria Healthcare NHS Foundation Trust

1 1

Nottingham University Hospitals NHS Trust

1 1 2

Oaklands Hospital, reported by NHS Salford CCG

1 1

Oxford Health NHS Foundation Trust 1 1

Oxford University Hospitals NHS Foundation Trust

1 1 3 5


Ad

min

istr

ati

on

of

me

dic

ati

on

by t

he w

ron

g r

ou

te

Fail

ure

to

in

sta

ll f

un

cti

on

al

co

lla

psib

le s

ho

wer

or

cu

rta

in

rail

s

Mis

sele

cti

on

of

a s

tro

ng

po

tass

ium

so

luti

on

Mis

sele

cti

on

of

hig

h

str

en

gth

mid

azo

lam

du

rin

g

co

nsc

iou

s s

ed

ati

on

Mis

pla

ce

d n

as

o o

r o

ro

gas

tric

tu

be

Ov

erd

os

e o

f in

su

lin

du

e t

o

ab

bre

via

tio

ns

or

inco

rre

ct

dev

ice

Ov

erd

ose o

f m

eth

otr

exa

te

for

no

n-c

an

ce

r tr

ea

tmen

t

Re

tain

ed

fo

reig

n o

bje

ct

po

st

pro

ce

du

re

Tra

ns

fus

ion

or

tra

nsp

lan

tati

on

of

AB

O

inco

mp

ati

ble

blo

od

co

mp

on

en

ts o

r o

rga

ns

Un

inte

nti

on

al c

on

ne

cti

on

of

a p

ati

en

t re

qu

irin

g o

xyg

en

to

an

air

flo

wm

ete

r

Wro

ng

im

pla

nt/

pro

sth

esis

Wro

ng

sit

e s

urg

ery

To

tal

Pennine Acute Hospitals NHS Trust 1 1 2

Pennine Care NHS Foundation Trust 1 1

Pennine MSK Partnership, reported by NHS Oldham CCG

1 1

Poole Hospital NHS Foundation Trust 1 1 2

Portsmouth Hospitals NHS Trust 2 2 1 1 6

Queen Elizabeth Hospital, King's Lynn NHS Foundation Trust

1 2 3

Ramsay Health Care - Springfield Hospital, reported by NHS Mid Essex CCG

1 1 2

Rivergreen Dental Practice, Nottingham, reported by NHS England Midlands

1 1


Ad

min

istr

ati

on

of

me

dic

ati

on

by t

he w

ron

g r

ou

te

Fail

ure

to

in

sta

ll f

un

cti

on

al

co

lla

psib

le s

ho

wer

or

cu

rta

in

rail

s

Mis

sele

cti

on

of

a s

tro

ng

po

tass

ium

so

luti

on

Mis

sele

cti

on

of

hig

h

str

en

gth

mid

azo

lam

du

rin

g

co

nsc

iou

s s

ed

ati

on

Mis

pla

ce

d n

as

o o

r o

ro

gas

tric

tu

be

Ov

erd

os

e o

f in

su

lin

du

e t

o

ab

bre

via

tio

ns

or

inco

rre

ct

dev

ice

Ov

erd

ose o

f m

eth

otr

exa

te

for

no

n-c

an

ce

r tr

ea

tmen

t

Re

tain

ed

fo

reig

n o

bje

ct

po

st

pro

ce

du

re

Tra

ns

fus

ion

or

tra

nsp

lan

tati

on

of

AB

O

inco

mp

ati

ble

blo

od

co

mp

on

en

ts o

r o

rga

ns

Un

inte

nti

on

al c

on

ne

cti

on

of

a p

ati

en

t re

qu

irin

g o

xyg

en

to

an

air

flo

wm

ete

r

Wro

ng

im

pla

nt/

pro

sth

esis

Wro

ng

sit

e s

urg

ery

To

tal

Rowley Hall Hospital, reported by NHS Stafford and Surrounds CCG

1 1

Royal Berkshire NHS Foundation Trust 1 1 2

Royal Brompton and Harefield NHS Foundation Trust

1 1

Royal Free London NHS Foundation Trust

1 2 3

Royal Liverpool and Broadgreen NHS Trust

2 2

Royal Orthopaedic Hospital NHS Foundation Trust

1 1

Royal Papworth Hospital NHS Foundation Trust

1 1

Royal United Hospitals Bath NHS Foundation Trust

1 1 2


Ad

min

istr

ati

on

of

me

dic

ati

on

by t

he w

ron

g r

ou

te

Fail

ure

to

in

sta

ll f

un

cti

on

al

co

lla

psib

le s

ho

wer

or

cu

rta

in

rail

s

Mis

sele

cti

on

of

a s

tro

ng

po

tass

ium

so

luti

on

Mis

sele

cti

on

of

hig

h

str

en

gth

mid

azo

lam

du

rin

g

co

nsc

iou

s s

ed

ati

on

Mis

pla

ce

d n

as

o o

r o

ro

gas

tric

tu

be

Ov

erd

os

e o

f in

su

lin

du

e t

o

ab

bre

via

tio

ns

or

inco

rre

ct

dev

ice

Ov

erd

ose o

f m

eth

otr

exa

te

for

no

n-c

an

ce

r tr

ea

tmen

t

Re

tain

ed

fo

reig

n o

bje

ct

po

st

pro

ce

du

re

Tra

ns

fus

ion

or

tra

nsp

lan

tati

on

of

AB

O

inco

mp

ati

ble

blo

od

co

mp

on

en

ts o

r o

rga

ns

Un

inte

nti

on

al c

on

ne

cti

on

of

a p

ati

en

t re

qu

irin

g o

xyg

en

to

an

air

flo

wm

ete

r

Wro

ng

im

pla

nt/

pro

sth

esis

Wro

ng

sit

e s

urg

ery

To

tal

Salford Royal NHS Foundation Trust 1 1

Salisbury NHS Foundation Trust 1 1

Sandwell and West Birmingham Hospitals NHS Trust

2 1 3

Sheffield Children's NHS Foundation Trust

1 1

Sheffield Teaching Hospitals NHS Foundation Trust

1 2 5 8

Shepton Mallet Treatment Centre, reported by NHS Somerset CCG

1 1

Sherwood Forest Hospitals NHS Foundation Trust

1 1

Smiles Orthodontics Dental Practice reported by NHS East and North Hertfordshire CCG

1 1


Ad

min

istr

ati

on

of

me

dic

ati

on

by t

he w

ron

g r

ou

te

Fail

ure

to

in

sta

ll f

un

cti

on

al

co

lla

psib

le s

ho

wer

or

cu

rta

in

rail

s

Mis

sele

cti

on

of

a s

tro

ng

po

tass

ium

so

luti

on

Mis

sele

cti

on

of

hig

h

str

en

gth

mid

azo

lam

du

rin

g

co

nsc

iou

s s

ed

ati

on

Mis

pla

ce

d n

as

o o

r o

ro

gas

tric

tu

be

Ov

erd

os

e o

f in

su

lin

du

e t

o

ab

bre

via

tio

ns

or

inco

rre

ct

dev

ice

Ov

erd

ose o

f m

eth

otr

exa

te

for

no

n-c

an

ce

r tr

ea

tmen

t

Re

tain

ed

fo

reig

n o

bje

ct

po

st

pro

ce

du

re

Tra

ns

fus

ion

or

tra

nsp

lan

tati

on

of

AB

O

inco

mp

ati

ble

blo

od

co

mp

on

en

ts o

r o

rga

ns

Un

inte

nti

on

al c

on

ne

cti

on

of

a p

ati

en

t re

qu

irin

g o

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en

to

an

air

flo

wm

ete

r

Wro

ng

im

pla

nt/

pro

sth

esis

Wro

ng

sit

e s

urg

ery

To

tal

Somerset Partnership NHS Foundation Trust

1 1

South Tees Hospitals NHS Foundation Trust

1 1 4 6

South Tyneside and Sunderland NHS Foundation Trust

1 1

South Warwickshire NHS Foundation Trust

2 2

Southampton Treatment Centre - Care UK, reported by NHS Southampton CCG

1 1 2

Southend University Hospital NHS Foundation Trust

1 2 3

Southport and Ormskirk Hospital NHS Trust

1 1


Ad

min

istr

ati

on

of

me

dic

ati

on

by t

he w

ron

g r

ou

te

Fail

ure

to

in

sta

ll f

un

cti

on

al

co

lla

psib

le s

ho

wer

or

cu

rta

in

rail

s

Mis

sele

cti

on

of

a s

tro

ng

po

tass

ium

so

luti

on

Mis

sele

cti

on

of

hig

h

str

en

gth

mid

azo

lam

du

rin

g

co

nsc

iou

s s

ed

ati

on

Mis

pla

ce

d n

as

o o

r o

ro

gas

tric

tu

be

Ov

erd

os

e o

f in

su

lin

du

e t

o

ab

bre

via

tio

ns

or

inco

rre

ct

dev

ice

Ov

erd

ose o

f m

eth

otr

exa

te

for

no

n-c

an

ce

r tr

ea

tmen

t

Re

tain

ed

fo

reig

n o

bje

ct

po

st

pro

ce

du

re

Tra

ns

fus

ion

or

tra

nsp

lan

tati

on

of

AB

O

inco

mp

ati

ble

blo

od

co

mp

on

en

ts o

r o

rga

ns

Un

inte

nti

on

al c

on

ne

cti

on

of

a p

ati

en

t re

qu

irin

g o

xyg

en

to

an

air

flo

wm

ete

r

Wro

ng

im

pla

nt/

pro

sth

esis

Wro

ng

sit

e s

urg

ery

To

tal

Spire - Clare Park, reported by NHS North East Hampshire and Farnham CCG

1 1

Spire - London East Hospital, reported by NHS Redbridge CCG

1 1

Spire - Manchester, reported by NHS Manchester CCG

1 1

Spire - Murrayfield, reported by NHS Wirral CCG

1 1

St George's University Hospitals NHS Foundation Trust

1 1 2 4

Stockport NHS Foundation Trust 1 1 2

Surrey and Sussex Healthcare NHS Trust

2 2


Ad

min

istr

ati

on

of

me

dic

ati

on

by t

he w

ron

g r

ou

te

Fail

ure

to

in

sta

ll f

un

cti

on

al

co

lla

psib

le s

ho

wer

or

cu

rta

in

rail

s

Mis

sele

cti

on

of

a s

tro

ng

po

tass

ium

so

luti

on

Mis

sele

cti

on

of

hig

h

str

en

gth

mid

azo

lam

du

rin

g

co

nsc

iou

s s

ed

ati

on

Mis

pla

ce

d n

as

o o

r o

ro

gas

tric

tu

be

Ov

erd

os

e o

f in

su

lin

du

e t

o

ab

bre

via

tio

ns

or

inco

rre

ct

dev

ice

Ov

erd

ose o

f m

eth

otr

exa

te

for

no

n-c

an

ce

r tr

ea

tmen

t

Re

tain

ed

fo

reig

n o

bje

ct

po

st

pro

ce

du

re

Tra

ns

fus

ion

or

tra

nsp

lan

tati

on

of

AB

O

inco

mp

ati

ble

blo

od

co

mp

on

en

ts o

r o

rga

ns

Un

inte

nti

on

al c

on

ne

cti

on

of

a p

ati

en

t re

qu

irin

g o

xyg

en

to

an

air

flo

wm

ete

r

Wro

ng

im

pla

nt/

pro

sth

esis

Wro

ng

sit

e s

urg

ery

To

tal

Tameside and Glossop Integrated Care NHS Foundation Trust

2 2

Taunton and Somerset NHS Foundation Trust

1 1

Tesco Plymouth Pharmacy, reported by NHS Somerset CCG

1 1

The Christie NHS Foundation Trust 1 1

The Dudley Group NHS Foundation Trust

1 1

The Hillingdon Hospital NHS Foundation Trust

1 1

The McIndoe Centre, reported by NHS High Weald Lewes Havens CCG

1 1

The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust

1

1 1 3


Ad

min

istr

ati

on

of

me

dic

ati

on

by t

he w

ron

g r

ou

te

Fail

ure

to

in

sta

ll f

un

cti

on

al

co

lla

psib

le s

ho

wer

or

cu

rta

in

rail

s

Mis

sele

cti

on

of

a s

tro

ng

po

tass

ium

so

luti

on

Mis

sele

cti

on

of

hig

h

str

en

gth

mid

azo

lam

du

rin

g

co

nsc

iou

s s

ed

ati

on

Mis

pla

ce

d n

as

o o

r o

ro

gas

tric

tu

be

Ov

erd

os

e o

f in

su

lin

du

e t

o

ab

bre

via

tio

ns

or

inco

rre

ct

dev

ice

Ov

erd

ose o

f m

eth

otr

exa

te

for

no

n-c

an

ce

r tr

ea

tmen

t

Re

tain

ed

fo

reig

n o

bje

ct

po

st

pro

ce

du

re

Tra

ns

fus

ion

or

tra

nsp

lan

tati

on

of

AB

O

inco

mp

ati

ble

blo

od

co

mp

on

en

ts o

r o

rga

ns

Un

inte

nti

on

al c

on

ne

cti

on

of

a p

ati

en

t re

qu

irin

g o

xyg

en

to

an

air

flo

wm

ete

r

Wro

ng

im

pla

nt/

pro

sth

esis

Wro

ng

sit

e s

urg

ery

To

tal

The Royal Free NHS Foundation Trust

1 1

The Royal Wolverhampton NHS Trust

1 1

The Walton Centre NHS Foundation Trust

1 1

The Westbourne Centre, reported by NHS West Midlands CCG

1 1

The Royal Orthopaedic Hospital NHS Foundation Trust

1 1

Torbay and South Devon NHS Foundation Trust

2 2

United Lincolnshire Hospitals NHS Trust

1

1 2 1 3 8


Ad

min

istr

ati

on

of

me

dic

ati

on

by t

he w

ron

g r

ou

te

Fail

ure

to

in

sta

ll f

un

cti

on

al

co

lla

psib

le s

ho

wer

or

cu

rta

in

rail

s

Mis

sele

cti

on

of

a s

tro

ng

po

tass

ium

so

luti

on

Mis

sele

cti

on

of

hig

h

str

en

gth

mid

azo

lam

du

rin

g

co

nsc

iou

s s

ed

ati

on

Mis

pla

ce

d n

as

o o

r o

ro

gas

tric

tu

be

Ov

erd

os

e o

f in

su

lin

du

e t

o

ab

bre

via

tio

ns

or

inco

rre

ct

dev

ice

Ov

erd

ose o

f m

eth

otr

exa

te

for

no

n-c

an

ce

r tr

ea

tmen

t

Re

tain

ed

fo

reig

n o

bje

ct

po

st

pro

ce

du

re

Tra

ns

fus

ion

or

tra

nsp

lan

tati

on

of

AB

O

inco

mp

ati

ble

blo

od

co

mp

on

en

ts o

r o

rga

ns

Un

inte

nti

on

al c

on

ne

cti

on

of

a p

ati

en

t re

qu

irin

g o

xyg

en

to

an

air

flo

wm

ete

r

Wro

ng

im

pla

nt/

pro

sth

esis

Wro

ng

sit

e s

urg

ery

To

tal

University College London Hospitals NHS Foundation Trust

1 2 3

University Hospital Southampton NHS Foundation Trust

1 1 3 5

University Hospitals Birmingham NHS Foundation Trust

1 1 4 6

University Hospitals Bristol NHS Foundation Trust

1 1 3 5

University Hospitals of Derby and Burton NHS Foundation Trust

4 4

University Hospitals of Leicester NHS Trust

1 2 3

University Hospitals of Morecambe Bay NHS Foundation Trust

1 1

University Hospitals of North Midlands NHS Trust

1 2 3


Ad

min

istr

ati

on

of

me

dic

ati

on

by t

he w

ron

g r

ou

te

Fail

ure

to

in

sta

ll f

un

cti

on

al

co

lla

psib

le s

ho

wer

or

cu

rta

in

rail

s

Mis

sele

cti

on

of

a s

tro

ng

po

tass

ium

so

luti

on

Mis

sele

cti

on

of

hig

h

str

en

gth

mid

azo

lam

du

rin

g

co

nsc

iou

s s

ed

ati

on

Mis

pla

ce

d n

as

o o

r o

ro

gas

tric

tu

be

Ov

erd

os

e o

f in

su

lin

du

e t

o

ab

bre

via

tio

ns

or

inco

rre

ct

dev

ice

Ov

erd

ose o

f m

eth

otr

exa

te

for

no

n-c

an

ce

r tr

ea

tmen

t

Re

tain

ed

fo

reig

n o

bje

ct

po

st

pro

ce

du

re

Tra

ns

fus

ion

or

tra

nsp

lan

tati

on

of

AB

O

inco

mp

ati

ble

blo

od

co

mp

on

en

ts o

r o

rga

ns

Un

inte

nti

on

al c

on

ne

cti

on

of

a p

ati

en

t re

qu

irin

g o

xyg

en

to

an

air

flo

wm

ete

r

Wro

ng

im

pla

nt/

pro

sth

esis

Wro

ng

sit

e s

urg

ery

To

tal

University Hospitals Plymouth NHS Trust

3 3

Warrington and Halton Hospitals NHS Foundation Trust

1 1

West Hertfordshire Hospitals NHS Trust

1 1 2

Western Sussex Hospitals NHS Foundation Trust

1 1

Weston Area Health NHS Trust 2 2

Whittington Health NHS Trust 2 2 4

Worcestershire Acute Hospitals NHS Trust

1 1 3 5

Wrightington, Wigan and Leigh NHS Foundation Trust

1 1 1 3


Ad

min

istr

ati

on

of

me

dic

ati

on

by t

he w

ron

g r

ou

te

Fail

ure

to

in

sta

ll f

un

cti

on

al

co

lla

psib

le s

ho

wer

or

cu

rta

in

rail

s

Mis

sele

cti

on

of

a s

tro

ng

po

tass

ium

so

luti

on

Mis

sele

cti

on

of

hig

h

str

en

gth

mid

azo

lam

du

rin

g

co

nsc

iou

s s

ed

ati

on

Mis

pla

ce

d n

as

o o

r o

ro

gas

tric

tu

be

Ov

erd

os

e o

f in

su

lin

du

e t

o

ab

bre

via

tio

ns

or

inco

rre

ct

dev

ice

Ov

erd

ose o

f m

eth

otr

exa

te

for

no

n-c

an

ce

r tr

ea

tmen

t

Re

tain

ed

fo

reig

n o

bje

ct

po

st

pro

ce

du

re

Tra

ns

fus

ion

or

tra

nsp

lan

tati

on

of

AB

O

inco

mp

ati

ble

blo

od

co

mp

on

en

ts o

r o

rga

ns

Un

inte

nti

on

al c

on

ne

cti

on

of

a p

ati

en

t re

qu

irin

g o

xyg

en

to

an

air

flo

wm

ete

r

Wro

ng

im

pla

nt/

pro

sth

esis

Wro

ng

sit

e s

urg

ery

To

tal

Wye Valley NHS Trust 2 3 5

Yeovil District Hospital NHS Foundation Trust

2 2

York Teaching Hospital NHS Foundation Trust 1

1 1 3

Total 7 1 1 3 18 5 6 71 3 22 37 176 350

Note: As described above, a further 31 Serious Incidents did not appear to meet the definition of a Never Event and the relevant organisations have been asked to review them accordingly. *Numbers are subject to change as local investigations are completed. ** Reported by North East Ambulance Service NHS Foundation Trust but appears related to an air flowmeter left in situ in University Hospital of North Durham.


Table 4: Never Events reported as occurring after 1 April 2019 but actually occurring prior to this

. None reported.

* Numbers are subject to change as local investigations are completed.

© NHS Improvement December 2019

Contact us: NHS England and NHS Improvement Wellington House 133-155 Waterloo Road London SE1 8UG 0300 123 2257 [email protected] improvement.nhs.uk This publication can be made available in a number of other formats on request

Documents

Provisional publication of Never Events reported as ... · 3 Provisional publication of Ne | ver Events reported as occurring 1 April - 31 December 2019 These standards set out broad